Out of Illness, Into Life: Pain Management and the Need for Triptans

In some ways, my favorite patients are those with no insurance. The reason? They choose reasonably. They choose the way America says it wants us to choose, in a cost-reasonable way that insured patients often feel little inclination to choose. Would one of my uninsured patients choose to take triptans several times a week? Not a chance. The costs would clearly be too high. My uninsured patient would be more likely happy with amitriptyline—preventing the headaches, for pennies a day. Of course, we would discuss the possibility of weight gain. But we’d handle that, possibly by a healthier hypoglycemic diet. My uninsured patient might not see me for months. The headaches that break through would be handled with over-thecounter drugs, occasional pain pills, or maybe that rare triptan if the “miseries” had really set in. The rest of the time the illness would be handled by prevention—combined with a healthy dose of reasonable expectations. Now, my headache colleagues might be saying “but these aren’t my patients, the ones with the really miserable migraines, the ones who feel miserable every day.” Actually, they are. They have the same biology. They just don’t have the same way of behaving with that biology. My uninsured patients don’t have easy lives. Many of them have fallen on quite hard times. They have the miseries. A lot of them just don’t discuss their anguish via their headaches. They have pain, but they don’t discuss it via “the pain.” And, part of the reason they don’t do this is because they can’t afford to manage the pain by taking all of this expensive medication to chase after it. They have migraine. They fulfill all the International Headache Society criteria. They just don’t find it practical to translate the pain of their life anguish into the pain called migraine. And so the migraine disease doesn’t become the way of being. Consider, in this regard, and for comparison, one of my favorite insured patients. She is a very nice young woman I’ve treated for years. She has migraine, and she has had “bad migraine” (whatever we may conceive of this to be in biological terms). In the last couple of years, she has had a very difficult time. Her headaches were very frequent and very difficult to treat in spite of all the best management strategies. She had her therapeutic layer of preventative mediations, her therapeutic layer of healthy lifestyle (diet, exercise, sleep, etc.), her therapeutic layer of trigger-factor controls (hormones, stress, foods, etc.), her therapeutic layer of ancillary techniques (biofeedback, acupuncture, chiropractic, etc.), her therapeutic layer of limited (nonrebound) analgesics, and, of course, her therapeutic layer of limited (nonrebound) abortives, including the triptans. Yet, she was doing poorly. Headaches were frequent. She was unhappy. Actually, I should turn that around: she was unhappy, headaches were frequent. She and her husband had been struggling for a long time. And, finally, she decided that in spite of her “being alone” fears, her 3 children, financial worries, and the rest, it was time for the two of them to go in different directions. She pursued divorce. It was difficult. But, there is a point to our story. She saw me recently—about 8 months into the divorce—and, beaming, she told me that she has not had a bad headache since her husband moved out. She still has the migraine illness. But, the illness is now vastly easier to control. Mostly, we are treating her anxiety at this point. Here is another experience to ponder. While recently at some neurological meetings, I took the opportunity, as I often do, to inquire of colleagues about how common illnesses are managed in other countries. I think this helps me to determine what is “necessary” and what is cultural. One of my colleagues at this meeting was from India. And, it so happens his mother had migraines. She lives in rural India. And, she has no insurance. So I asked, “What does your mother do to treat her headaches?” His answer: “When she gets them, she lays down for about half an hour.” Apparently this is her major form of treatment. Of course, this is “N=1.” This is anecdotal. And, in a rural setting, it might be more practical to lie down for half an hour. Yet, this is a worthwhile piece of information. This is inexpensive treatment, and she feels it is acceptable. And, here is one more story. I was recently reading the report of another neurologist in which he described one of his patients who was on a great deal of medication for migraines. She was in his office complaining of severe migraine. He was evaluating what to do next. He reported that on her analog pain scale, she reported pain being 9 out of 10 (10 being the score of “the worst pain imaginable”). So, by her appraisal, she was very close to the most extreme end of the scale. Yet, interestingly, on his exam, he observed her to be “a woman in no apparent distress,” and he didn’t seem bothered by the disparity. It is actually rather common to see patients who report having severe headaches—including at the moment of evaluation—while physical examination reveals the patient appearing normal, or even cheerful. This disparity is so common that it often no longer even generates recognition. Yet, isn’t it revealing? Intriguingly, in my patients with no insurance, this is rather rare. If they have a bad migraine, they look ill. The notion of “bad migraine” is complex. For a few patients, it is the presentation of visible misery. During a bad migraine, the patient may appear pale, diaphoretic, obviously nauseated, and withdrawn into wincing pain. Yet, it is quite routine to see patients who report having “bad migraine” illness where this is never really observed. Instead, the patient presents to the office with major report of pain but, often, remarkably little evidence of pain (although perhaps the haggard appearance of chronic stress). When the literature talks about “bad migraine,” it does not talk about patients who are measured to have bad physiology (analogous to a patient with bad cancer who has metastases everywhere, or a cardiac patient with bad heart disease who has ankles the size of calves). Rather, literature discussions of “bad migraine” tend to proceed based on patient claims of pain, often “measured” via instruments such as a visual analog scale, that really only succeed in documenting a claim. Therefore, discussions of “bad migraine” need to be recognized as not the scientific equivalent of many of Editorials

It was difficult. But, there is a point to our story. She saw me recently-about 8 months into the divorce-and, beaming, she told me that she has not had a bad headache since her husband moved out. She still has the migraine illness. But, the illness is now vastly easier to control. Mostly, we are treating her anxiety at this point.
Here is another experience to ponder. While recently at some neurological meetings, I took the opportunity, as I often do, to inquire of colleagues about how common illnesses are managed in other countries. I think this helps me to determine what is "necessary" and what is cultural. One of my colleagues at this meeting was from India. And, it so happens his mother had migraines. She lives in rural India. And, she has no insurance. So I asked, "What does your mother do to treat her headaches?" His answer: "When she gets them, she lays down for about half an hour." Apparently this is her major form of treatment. Of course, this is "N=1." This is anecdotal. And, in a rural setting, it might be more practical to lie down for half an hour. Yet, this is a worthwhile piece of information. This is inexpensive treatment, and she feels it is acceptable.
And, here is one more story. I was recently reading the report of another neurologist in which he described one of his patients who was on a great deal of medication for migraines. She was in his office complaining of severe migraine. He was evaluating what to do next. He reported that on her analog pain scale, she reported pain being 9 out of 10 (10 being the score of "the worst pain imaginable"). So, by her appraisal, she was very close to the most extreme end of the scale. Yet, interestingly, on his exam, he observed her to be "a woman in no apparent distress," and he didn't seem bothered by the disparity.
It is actually rather common to see patients who report having severe headaches-including at the moment of evaluation-while physical examination reveals the patient appearing normal, or even cheerful. This disparity is so common that it often no longer even generates recognition. Yet, isn't it revealing? Intriguingly, in my patients with no insurance, this is rather rare. If they have a bad migraine, they look ill.
The notion of "bad migraine" is complex. For a few patients, it is the presentation of visible misery. During a bad migraine, the patient may appear pale, diaphoretic, obviously nauseated, and withdrawn into wincing pain. Yet, it is quite routine to see patients who report having "bad migraine" illness where this is never really observed. Instead, the patient presents to the office with major report of pain but, often, remarkably little evidence of pain (although perhaps the haggard appearance of chronic stress). When the literature talks about "bad migraine," it does not talk about patients who are measured to have bad physiology (analogous to a patient with bad cancer who has metastases everywhere, or a cardiac patient with bad heart disease who has ankles the size of calves). Rather, literature discussions of "bad migraine" tend to proceed based on patient claims of pain, often "measured" via instruments such as a visual analog scale, that really only succeed in documenting a claim. Therefore, discussions of "bad migraine" need to be recognized as not the scientific equivalent of many of So, with these 3 stories, we may then return to the perception of "need" for triptans. As in other realms of life, perception is a critical aspect of perceived need. My uninsured patients do not perceive that they need great quantities of these expensive medications. On the other hand, my insured patients may feel that they do. So, what part of this "need" is biology, and what part is sociology?
Even in my own patients that I have revealed above, the issues are not simple. I knew my young female patient with refractory headaches was suffering anguish as much as migraine. But, I also knew that she was not willing to "go there." So, I managed the illness as well as I could under biological approaches while still discussing with her that high-grade stress was actually the cause of her refractory state (later confirmed). When she was ready, she could obtain more effective solutions.
The management of pain, whether under the auspices of migraine or some other mechanism, is complex. Unlike congestive heart failure, renal failure, or a host of other clearly structural problems, the management of pain is a management of mixed issues: partly biology, partly psychology, and partly sociology. Physicians may choose to ignore the latter 2 factors because of the convenience of doing so. However, high cost and excessive service will be the result. And, in the final analysis, the patient' s quality of life will deteriorate.
In this issue of the Journal, Adelman and Belsey examine the relative cost-effectiveness of triptans. The erudite work by the authors adds to our perspective of choices within the class. But, possibly, it makes a subtle yet critical transition that is problematical. The initial portions of the article address quite well the cost considerations between drugs. However, the latter portion of the article presumes that freer use of triptans may reduce costs overall by reducing emergency room visits. However, as a headache specialist, it is my opinion that the best way to reduce ER visits is to prevent the headaches. And, triptans are not effective in that regard. If patients excessively chase after the headaches, they tend to beget more of the same-chasing after the headaches. This is not ultimately the route to reducing costs. So, the class of drugs is certainly excellent. And, the authors help us choose among the class for appropriate use. However, in my opinion, freer use of abortives may only abort, and not control.

John P. Barbuto, MD
Neurology In Focus An Outpatient Neurology Clinic at HealthSouth